Changes In Medication Adherence Research Articles

A Mobile App for Chronic Disease Self-Management for Individuals with Low Health Literacy: A Multisite Randomized Controlled Clinical Trial

The purpose of this study was to evaluate the effects of a mobile app designed to improve chronic disease self-management in patients aged 40 years and older with low health literacy and who had at least one chronic health condition, and to assess the impact of delivering information at different levels of reading difficulty. A randomized controlled trial was completed at two sites. Individuals aged 40 years and older screened for low health literacy who had at least one chronic health condition were randomly assigned to a tailored information multimedia app with text at one of three grade levels. Four primary outcomes were assessed: patient activation, chronic disease self-efficacy, health-related quality of life, and medication adherence. All groups showed overall increases in activation, self-efficacy, and health-related quality of life, but no change in medication adherence. No between-group differences were observed. The mobile app may have been effective in increasing participants’ levels of several psychosocial variables, but this interpretation can only be advanced tentatively in light of the lack of control-experimental group differences. Reading difficulty level was not significantly related to outcomes.

Interventions to improve medication adherence in adults with mental-physical multimorbidity in primary care: a systematic review.

Medication non-adherence is a notable contributor to healthcare inefficiency, resulting in poor medication management, impaired patient outcomes, and ineffective symptom control. To summarise interventions targeting medication adherence for adults with mental-physical multimorbidity in primary healthcare settings. A systematic review of the literature - published in any language and with any country of origin - was conducted. MEDLINE, EMBASE, PsycInfo, Web of Science, Cochrane Library, and the Cumulated Index to Nursing and Allied Health Literature - more commonly known as CINAHL - were searched for relevant studies. Data were extracted and synthesised using narrative synthesis. The Effective Practice and Organisation of Care (EPOC) taxonomy was used to classify intervention types. Risk of bias was assessed using the National Heart, Lung, and Blood Institute's quality assessment tool for controlled intervention studies. Eleven studies, representing 2279 patients, were included. All interventions examined were classified into one EPOC domain, namely 'delivery arrangements'. All included studies examined patients who had a physical condition and depression. Seven studies examining interventions focused on coordination of care and management of care processes reported statistically significant improvements in medication adherence that were attributed to the intervention. Four studies considering the use of information and communication technology observed no changes in medication adherence. Interventions that coordinate and manage healthcare processes may help improve patients' adherence to medication regimes in those with mental-physical multimorbidity. However, it is still necessary to better understand how digital health technology can support patients in following their medication regimes. As the growing challenges of treating multimorbidity are faced, everyone involved in health services - from providers to policymakers - must be receptive to a more integrated approach to healthcare delivery.

The mediating effect of self-efficacy on the relationship between social support and medication adherence in adults with type 2 diabetes.

To evaluate the status of medication adherence in diabetic patients and its effective factors. A cross-sectional descriptive study was conducted with 170 diabetic patients in Iran. Participants were assessed for medication adherence, self-efficacy, and social support. Descriptive statistics, bivariate analyses, and multiple stepwise regression were conducted to explore predictors for medication adherence. Regression analysis showed that 48% of medication adherence changes stemmed from the four variables including social support, self-efficacy, income, and education levels, (R2adj = 0.480, F = 39.943, p < 0.001). According to the model, the highest effects were related to income level (β = 0.332, t = 5.493, p ⩽ 0.001) and self-efficacy (β = 0.330, t = 4.789, p ⩽ 0.001), respectively. Based on the final model, only the social support variable showed no significant relationship with adherence (β = 0.002, t = 0.032, p = 0.947). Social support and self-efficacy were related to medication adherence in diabetic patients, and social support can improve medication adherence in patients with diabetes by affecting self-efficacy. Healthcare workers who interact with individuals with diabetes should take into account the factors mentioned above when designing health promotion interventions to address the needs of these individuals.

The impact of the Sri Lankan economic crisis on medication adherence: An online cross-sectional survey.

The economic crisis in Sri Lanka has disarrayed the country's healthcare services, posing a challenge to people with chronic diseases on routine care. This study investigated the changes in medication adherence during the economic crisis. A web-based cross-sectional survey was undertaken in July-August 2022. It assessed socio-demographics, diseases, medication adherence, and reasons for changes in compliance of respondents and their family members during the economic crisis. Descriptive statistics and multivariable logistic regression analysis were used. A total of 1214 respondents, aged ≥18years were included in the survey. The majority were females (60%). The main finding was that 39%, 41%, and 37% of participants, their family members, or children respectively have changed medication use during the crisis. Among those who changed their medication practices, the most significant change was the change in the brand, reported by 44.7% of the respondents. A similar pattern was observed among other family members, with 61.3% of adults and 53.8% of children switching brands. Respondents who lived outside the Colombo district had a significantly increased risk of changing medication (OR=1.425, 95% CI=1.020-1.992, P=0.038). Respondents with monthly incomes of less than 100,000 LKR had a twofold greater risk of medication nonadherence compared to participants who earned more than 100,000 LKR per month (OR=2.278, 95% CI=1.37-3.78, P=0.001). The most stated reason for changing medication among adults was the high cost of drugs, whereas among, children, the lack of access to drugs in the public or private sector was the leading cause of non-compliance. The population's adherence to medication is negatively impacted by the economic crisis in Sri Lanka.

Telephone-based social health screening by pharmacists in the nonadherent Medicare population.

BACKGROUND: Unmet social health needs are associated with medication nonadherence. Although pharmacists are well positioned to address medication nonadherence, there is limited experience with screening for and addressing social health needs. OBJECTIVES: To compare the prevalence of social health needs among Medicare patients with higher vs lower social health risk using a predictive model. To also evaluate pre-post changes in medication adherence and health care use following a pharmacist-initiated social health screening. METHODS: A social health screening workflow was implemented into a routine pharmacist adherence program at an integrated health care delivery system. The social health screening was conducted during medication adherence outreach phone calls with Medicare members who were overdue for statin, blood pressure, or diabetes medications. We developed a social health need predictive algorithm to flag higher-risk patients and tested this algorithm against a random subset of lower-risk patients. Screening conversations were guided by a focus group that developed open-ended questions to identify social health needs. Comparisons in social health needs were made between higher- and lower-risk patients. Use and adherence outcomes were compared pre and post for patients who accepted a referral to social health resources and patients who declined a referral. RESULTS: 1,217 patients were contacted and screened for social health needs by pharmacists. Patients flagged by the social risk algorithm were more likely to report social health needs (28.7% vs 12.7% in the unflagged group; P < 0.01). Commonly reported needs included transportation (43%), finances (34%), caregiving (22%), mental health (11%), and food access (10%). 221 patients accepted a referral to a central resource website and call center that connected patients to local services. One year after screening dates, patients who did not accept a referral spent more time in the hospital (mean change +0.7 days, SD = 7.3, P < 0.01), had fewer primary care visits (mean change -0.5 visits, SD = 6.5, P < 0.01), and had a shorter length of membership (mean change -0.4 months, SD = 1.9, P < 0.01). Patients who accepted a referral had increased statin adherence (62.3% adherent pre vs 74.7% post, P = 0.02). CONCLUSIONS: We implemented a workflow for pharmacists to screen for social health needs. The social health need prediction model doubled the identification rate of patients who have needs. Intervening on social health needs during these calls may improve statin adherence and may have no adverse effect on health care utilization or health plan membership. DISCLOSURES: Social health risk predictive model development and validation was funded by the Agency for Healthcare Research and Quality (AHRQ R18HS027343).

Examining the relationship between depression and medication adherence among elderlies suffering from cardiovascular disease referring to the clinics affiliated with Kermanshah Universityof Medical Sciences: A cross-sectional study.

In recent years, around 30% of all mortalities worldwide has been related to cardiovascular disease (CVD).The most important predictor solution of cardiovascular events is enhancing medication adherence. Meanwhile, the main reason behind development of physical disorders among the elderlyis depression. In this regard, the present research was performed to determine the relationship between depression and medication adherence among the elderlysuffering from CVD. A cross-sectional study was done via an analytical approach on 188 elderlies fulfilling the inclusion criteria. The participants were chosen through convenience nonrandomized sampling from March to July 2022. The data were collected through demographic and healthcare information form plus Madanloo chronic disease medication adherence and geriatric depression scale. The analysis of the data was done by SPSS 26 plus Stata 14.2. The mean depression score was 5.6(4.3) and the mean score of medication adherence in the elderlies was 168.03(23.85). The prevalence of depression was higher in women than in men (p = 0.015), and the elderlies differing from heart failure reported the minimum extent of medication adherence. The findings obtained from analysis of variance showed that age, level of education, and monthly level of income were among the effective demographic factors in the extent of depression and medication adherence (p < 0.05). Meanwhile, 26% of changes in medication adherence can be attributed to depression. Further, the results of the multiple linear regression model reported that depression, age, and polypharmacy are among the predictors of medication adherence. A weak to moderate relationship existed between depression and medication adherence among these elderlies. Given the growing elderly population, the importanceof depression, and lack of medication adherence in incidence of CVD events, it is recommended to train the healthcare team tomonitorthe elderlyregarding depression symptoms.

A nurse-led multicomponent behavioral activation intervention for patients with atrial fibrillation: a randomized controlled trial

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Grants Committee of Hong Kong through the General Research Fund Introduction Patients with atrial fibrillation (AF) often play a passive role in the treatment decision-making process, rendering jeopardized health-related quality of life, suboptimal medication optimization and self-care. Purpose This study aimed to examine the effects of a Nurse-led Multicomponent Behavioral Activation (N-MBA) intervention on HRQoL, knowledge about AF, medication adherence and psychological distress among patients with AF. Methods This parallel two-arm randomized controlled trial recruited community-dwelling patients aged ≥65 years with a confirmed diagnosis of atrial fibrillation, moderate to high risk of stroke but not receiving oral anticoagulation. Participants were randomized in a 1:1 ratio to receive the N-MBA intervention or standard care. The 13-week intervention adopted a novel behavioral activation approach to equip AF patients as an active agent to manage the disease. It consisted of care components to prepare patients for shared decision-making by using a decision aid, an empowerment-based educational module covering relevant AF self-care topics and continuous support through telephone calls. A set of validated instruments was administered at baseline, immediate and 6 months post-intervention. Results A total of 252 participants were randomized to the intervention (n = 127) or control (n = 125) group. Compared with the control group, the intervention group showed greater improvements in HRQoL [β = 10.617, 95% confidence interval (CI) = 1.285 – 20.501, p = 0.023] and AF knowledge (β = 2.129, 95% CI =1.026 – 5.712, p &amp;lt;0.001) at immediate post-intervention. The effects on both outcomes sustained at 6-month follow-up time point. No significant between-group changes in medication adherence, anxiety and depression were detected. Participants in the intervention group were activated to raise their concerns about AF and its treatment with the attending doctors, and they perceived higher compatibility between patient and physician decisions of OAC use upon completion of the intervention. Conclusion The empowerment-based nurse-led intervention is effective at sustaining improvements in HRQoL, AF knowledge and treatment decision making in AF patients with moderate to high stroke risk. It does not increase their psychological distress.

Using the integrated theory of health behavior change to assess factors affecting diabetes medication adherence among black adults during COVID-19: an explanatory sequential mixed methods design

ABSTRACT Objectives (1) Evaluate changes in medication adherence and the role of psychosocial and interpersonal factors on adherence. (2) Explain the changes in medication adherence based on patient perceptions of adherence behaviors. Design We used an explanatory sequential mixed methods design for surveys at baseline and 1-year follow-up, followed by interviews. The Integrated Theory of Health Behavior Change guided the design of a questionnaire including self-reported measures of medication adherence, psychosocial factors such as illness and medication beliefs, self-efficacy, and depressive symptoms, interpersonal factors including social support and patient-provider communication, and socio-demographic and clinical factors. A convenience sample (n = 228) of adult patients with type 2 diabetes who self-identified as Black/African American completed the mail/telephone surveys. Nine semi-structured interviews were conducted with respondents of both surveys who had changes in medication adherence. Descriptive, mean differential, bivariate correlational analyses, and content analysis was conducted. Data integration merged quantitative and qualitative results as a joint display. Results Response rates for the baseline and follow-up survey were 28% and 47% respectively. Medication adherence scores were significantly correlated with illness perceptions (r = .30) and depression (r = .25) at baseline, and self-efficacy (r = −.51) and depression (r = .37) at follow-up. Qualitative themes included patient perceptions of adherence behaviors, impact of the COVID-19 pandemic, health literacy and self-efficacy. Mixed methods integration showed contrasting perceptions of the same themes including adherence behaviors, medication beliefs, social support, and patient-provider communication among participants whose medication adherence increased and decreased overtime. Conclusion Self-efficacy, diabetes beliefs, and depressive symptoms were key psychosocial factors that affected medication adherence among Blacks/African Americans. Contrasting perceptions of beliefs in medicines, social support, provider relationships and communication among increased and decreased adherence participant groups explained the changes in adherence, which can be used to adapt existing interventions.

Improved Medication Adherence with the Use of Extended-Release Tacrolimus in Liver Transplant Recipients: A Pilot Randomized Controlled Trial.

Nonadherence to immunosuppression in liver transplant recipients (LTRs) leads to deterioration in health outcomes. Once-dailyextended-release tacrolimus (TAC-ER) may improve adherence when compared to twice-dailyimmediate-release tacrolimus (TAC-IR). We conducted a randomized controlled study to evaluate medication adherence, clinical efficacy, and safety of TAC-ER in stable LTR. All patients >18 years who underwent liver transplantation before 6 months were eligible. Patients were randomized 1 : 1 to continued TAC-IR or conversion to TAC-ER. The primary outcome was change in medication adherence from baseline to 9 months, assessed using BAASIS. Secondary outcomes were tacrolimus trough levels, safety, and quality of life. Thirty-one patients were consented and randomized to either of the two groups: conversion to TAC-ER (n = 15) or continued TAC-IR (n = 16). Six patients in the TAC-ER group withdrew after randomization due to apprehension about switching medication (n = 2), unwillingness to travel (n = 2), and increased liver tests after conversion (n = 2, both were acute rejections despite therapeutic tacrolimus levels and were considered unrelated to TAC-ER). We compared the results of nine patients in the TAC-ER group that completed the study with those of sixteen in the TAC-IR group. At baseline, there was no difference in tacrolimus trough levels between groups. Improved adherence was observed in the TAC-ER group as 100% of patients reported at least one period of full adherence during the study period (100% vs. 62.6%, p = 0.035). Tacrolimus trough levels and liver tests were comparable between groups throughout the study. There were no differences in eGFR, HbA1c, or QoL between the groups. TAC-ER improved medication adherence while maintaining comparable trough levels, liver function, and QoL as TAC-IR in LTR.

Medication Adherence in Medicare-Enrolled Older Adults with Chronic Obstructive Pulmonary Disease before and during the COVID-19 Pandemic.

Medication adherence to controller inhalers was unknown in older Medicare patients with chronic obstructive pulmonary disease (COPD) before and during the pandemic. This study evaluated changes in medication adherence to controller medications and factors associated with high adherence. This retrospective cohort study included older Medicare patients with COPD. The proportion of days covered (PDC) reflected changes in medication adherence from January to July in 2019 and in 2020. Paired t-test evaluated changes in adherence. Logistic regression determined the association of patient characteristics with high adherence (PDC ≥ 80%). Mean adherence decreased (p < 0.001) for long-acting beta-agonists, long-acting muscarinic antagonists, and inhaled corticosteroids in 2020. The percentage of patients with high adherence dropped from 74.4% to 58.1% (p < 0.001). The number of controllers, having ≥3 albuterol fills, and a 90-day supply were associated with high adherence in 2019 and 2020 (p < 0.001). The COVID-19 pandemic may negatively impact medication adherence. Patients with evidence of more severe diseases and a 90-day supply were more likely to adhere to therapy. Healthcare professionals should prioritize prescribing 90-day supplies of medications and monitor drug-related problems as components of pharmacovigilance to enhance adherence to therapies and the desired clinical outcomes among patients with COPD.

Nurse-led multi-component behavioural activation programme to improve health outcomes in patients with atrial fibrillation: a mixed-methods study and feasibility analysis.

Patients with atrial fibrillation (AF) play passive roles in disease management. This study aimed to examine the feasibility and preliminary effects of an empowerment-based care model, titled 'the nurse-led multi-component behavioural activation (N-MBA) programme', on health-related quality of life, AF knowledge, psychological outcomes, medication adherence, and treatment decision-making in patients with AF. This mixed-methods study comprised a pilot randomized controlled trial and a qualitative study. Patients with AF who had a moderate-to-high risk of stroke but were not prescribed oral anticoagulants were recruited. Forty participants were recruited and randomized in a 1:1 ratio to receive either the N-MBA programme or standard care. The 13-week programme comprised care components that prepared patients for shared decision-making, an empowerment-based educational module on AF self-care, and continuous support through telephone calls. The programme was feasible, and the overall attendance rate was 82.5%. The participants gave excellent ratings in the satisfaction survey. The N-MBA group showed greater improvements in health-related quality of life (HRQoL) and AF knowledge than the standard care group at the immediate post intervention and 6-month follow-up time points. No significant between-group changes in medication adherence, anxiety, and depression were detected. Participants in the N-MBA group actively raised concerns about AF and its treatment with their attending doctors. The qualitative data were consistent with the quantitative data, indicating that the programme built a comprehensive knowledge base of AF and self-care behaviours. The N-MBA programme is feasible and acceptable to patients with AF. It improved patients' AF knowledge, treatment-related decision-making, and HRQoL. ClinicalTrials.gov NCT03924739.

Abstract 13482: Feasibility Analysis of a Nurse-Led Empowerment-Based Care Model in Supporting Treatment Decision-Making and Self-Care Among Patients With Atrial Fibrillation

Introduction: Patients with atrial fibrillation (AF) play a passive role in the treatment decision-making process, rendering suboptimal medication optimization and poor self-care. This pilot study aimed to examine the feasibility and preliminary effects of a nurse-led empowerment-based intervention among AF patients. Methods: This study comprised a pilot randomized controlled trial and an exploratory qualitative phase. AF patients who had moderate to high risk of stroke but not receiving oral anticoagulation were recruited. Participants (N = 40) were randomized in 1:1 ratio to receive the intervention or standard care. The 13-week intervention adopted a novel behavioral activation approach to equip AF patients as an active agent to manage the disease. It consisted of care components to prepare patients for shared decision-making by using a decision aid, an empowerment-based educational module covering relevant AF self-care topics and continuous support through telephone calls. Ten participants in the intervention group attended a qualitative interview to explore their engagement experience and perceived feasibility. Results: The intervention was highly feasible and participants gave excellent rating for the satisfaction survey. The overall attendance rate was 82.5%. Compared with the standard care group, the intervention group showed greater improvements in health-related quality of life (HRQoL) [β = -10.617, (95% CI = -20.350 - -0.885), p = 0.033] and AF knowledge [β = 1.950, (95% CI =1.026 - 2.874), p &lt;0.001] at immediate post-intervention. The effects on both outcomes sustained at 6-month follow-up time point. No significant between-group changes in medication adherence, anxiety and depression were detected. Participants in the intervention group were activated to raise their concerns about AF and its treatment with the attending doctors. The qualitative data highlighted the uniqueness of the empowerment process of the intervention in improving their knowledge and self-care behaviors. Conclusions: The empowerment-based nurse-led intervention is highly feasible and acceptable for AF patients. It improved HRQoL, AF knowledge and treatment decision making in AF patients. It did not increase anxiety and depression.

Abstract 13007: Assessing Patient Engagement With a Mobile Health Application for Self-Care Of Heart Failure in a Real-World Setting

Background: Consumer-facing mobile health applications (mHealth apps) are being increasingly integrated into routine heart failure (HF)-related self-care. However, there is a dearth of research on patient engagement with consumer-facing mHealth apps in real-world settings and the effect of such engagement on HF outcomes. Objectives: This study examine the patterns of patient engagement with a consumer-facing mHealth app,and the effects of engagement on HF outcomes. Method: This was a longitudinal observational study of patients who used a consumer-facing mHealth app, OnTrack to Health, for self-care of HF in a real-world setting between 2012 and 2020. Patient engagement was assessed as the percentage of assigned self-care activities checked off and transmitted daily to the nursing team via the app interface, within the first 575 days of use. Bilinear spline growth models were used to examine patterns of patient engagement during free subscription and post-free subscription periods and to determine the predictors of the engagement. The effects of patient engagement on medication adherence were examined using linear mixed effect models. Results: A total of 229 participants (148/229, 64.6% male), with a mean age of 62.2 (SD 14) years used the app. The mean (SD) daily patient engagement and medication adherence were 77.3 (27.5)%, and 98.4 (3.7)%, respectively. Patient engagement with OnTrack to Health app decreased overtime during the free subscription (β -.490, 95% CI -0.796 to -0.184, P = .002 ) and post-free subscription patient engagement(β -.567, 95% CI -0.860 to -0.272, P &lt;.001) periods, attainment of target doses of guideline-directed medical therapy (β .002, 95% CI 0.001 to 0.003, P &lt;.001), and being a long-term vs. short-term app user (β .191, 95% CI 0.063 to 0.319, P =.003) were associated with a higher rate of patient engagement over time. Patient engagement was not significantly associated with the rates of changes in medication adherence over time (β .002, 95% CI -0.003 to 0.007, P= .360) Conclusion: The declining trend of patient engagement with consumer-grade apps, indicates a need for effective strategies to sustain patient engagement, and such strategies may include financing models that place no or minimal financial responsibility on patients.

Role of Subsidized Coverage Eligibility in Medication Adherence Among Patients With Hypertension and Diabetes: Evidence From the NHIS 2011–2018

The subsidized insurance provision under the Affordable Care Act is an important instrument for health insurance coverage among middle-income nonelderly individuals. However, unlike the health impacts of the Medicaid expansion under the Affordable Care Act, the impact of subsidized insurance is relatively less explored in extant literature. This study aims to assess the role of subsidized coverage eligibility in medication adherence among nonelderly patients with hypertension and diabetes in the U.S. Using pooled data from 8 rounds (2011-2018) of the National Health Interview Survey, we estimated a difference-in-differences model to examine the change in medication adherence among study participants with a household income of 150%-399% of the Federal Poverty Line compared with that among their counterparts with a household income of ≥400% of the Federal Poverty Line during pre‒ and post‒Affordable Care Act periods. We also performed event study analysis and falsification tests to check the validity of our quasi-experimental design. Analyses were conducted in 2022. Medication adherence in the treatment group increased by 4.5 percentage points (95% CI=2.8, 6.2) during the post‒Affordable Care Act periods, whereas the increase was only 1.8 percentage points (95% CI=0.6, 3.0) in the control group. Results of the difference-in-differences model suggest that because of the subsidized insurance under the Affordable Care Act, medication adherence in the treatment group increased by 3.1 percentage points (95% CI=1.0, 5.2) during the post‒Affordable Care Act periods, compared with that in the control group. This increase was attributable to the improved insurance coverage, which increased by 6.8 percentage points (95% CI=5.3, 8.4) in the treatment during the post‒Affordable Care Act periods. Our analyses generate evidence that middle-income individuals with hypertensive or diabetic conditions, who were eligible for the subsidized coverage, benefited from this provision of the Affordable Care Act.

Association Between Telemedicine Use in Nonmetropolitan Counties and Quality of Care Received by Medicare Beneficiaries With Serious Mental Illness

Access to specialty mental health care remains challenging for people with serious mental illnesses, such as schizophrenia and bipolar disorder. Whether expansion of telemedicine is associated with improved access and quality of care for these patients is unclear. To assess whether greater telemedicine use in a nonmetropolitan county is associated with quality measures, including use of specialty mental health care and medication adherence. In this cohort study, the variable uptake of telemental health visits was examined across a national sample of fee-for-service claims from Medicare beneficiaries in 2916 nonmetropolitan counties between January 1, 2010, and December 31, 2018. Beneficiaries with schizophrenia and related psychotic disorders and/or bipolar I disorder during the study period were included. For each year of the study, each county was categorized based on per capita telemental health service use (none, low, moderate, and high). The association between telemental health service use in the county and quality measures was tested using a multivariate model controlling for both patient characteristics and county fixed effects. Analyses were conducted from January 1 to April 11, 2022. Before the COVID-19 pandemic, telemedicine reimbursement was limited to nonmetropolitan beneficiaries. Receipt of a minimum of 2 specialty mental health service visits (telemedicine or in-person) in the year, number of months per year with medication, hospitalization rate, and outpatient follow-up visits after a mental health hospitalization in a year. In 2018, there were 2916 counties with 118 170 patients (77 068 [65.2%] men; mean [SD] age, 58.3 [15.6] years) in the sample. The fraction of counties that had high telemental health service use increased from 2% in 2010 to 17% in 2018. In 2018 there were 1.08 telemental health service visits per patient in the high telemental health counties. Compared with no telemental health care in the county, patients in high-use counties were 1.2 percentage points (95% CI, 0.81-1.60 percentage points) (8.0% relative increase) more likely to have a minimum number of specialty mental health service visits, 13.7 percentage points (95% CI, 5.1-22.3 percentage points) (6.5% relative increase) more likely to have outpatient follow-up within 7 days of a mental health hospitalization, and 0.47 percentage points (95% CI, 0.25-0.69 percentage points) (7.6% relative increase) more likely to be hospitalized in a year. Telemental health service use was not associated with changes in medication adherence. The findings of this study suggest that greater use of telemental health visits in a county was associated with modest increases in contact with outpatient specialty mental health care professionals and greater likelihood of follow-up after hospitalization. No substantive changes in medication adherence were noted and an increase in mental health hospitalizations occurred.

Integrating behavioral health & primary care for multiple chronic diseases: Clinical trial of a practice redesign toolkit.

Context: Most patients in need of behavioral health (BH) care are seen in primary care, which often has difficulty responding. Some practices integrate behavioral health care (IBH), with medical and BH providers at the same location, working as a team. However, it is difficult to achieve high levels of integration. Objective: Test the effectiveness of a practice intervention designed to increase BH integration. Study Design: Pragmatic, cluster-randomized controlled trial. Setting: 43 primary care practices with on-site BH services in 13 states. Population: 2,460 adults with multiple chronic medical and behavioral conditions. Intervention: 24-month practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Outcomes: Primary outcomes were changes in the 8 Patient-Reported Outcomes Measurement Information System (PROMIS-29) domain scores. Secondary outcomes were changes in medication adherence, self-reported healthcare utilization, time lost due to disability, cardiovascular capacity, patient centeredness, provider empathy, and several condition-specific measures. A sample of practice staff completed the Practice Integration Profile at each time point to estimate the degree of BH integration in that site. Practice-level case studies estimated the typical costs of implementing the intervention. Results: The intervention had no significant effect on any of the primary or secondary outcomes. Subgroup analyses showed no convincing patterns of effect in any populations. COVID-19 was apparently not a moderating influence of the effect of the intervention on outcomes. The intervention had a modest effect on the degree of practice integration, reaching statistical significance in the Workflow domain. The median cost of the intervention was $18,204 per practice. In post-hoc analysis, level of BH integration was associated with improved patient outcomes independent of the intervention, both at baseline and longitudinally. Conclusions: The specific intervention tested in this study was inexpensive, but had only a small impact on the degree of BH integration, and none on patient outcomes. However, practices that had more integration at baseline had better patient outcomes, independent of the intervention. Although this particular intervention was ineffective, IBH remains an attractive strategy for improving patient outcomes.

Supporting People With Type 2 Diabetes in the Effective Use of Their Medicine Through Mobile Health Technology Integrated With Clinical Care to Reduce Cardiovascular Risk: Protocol for an Effectiveness and Cost-effectiveness Randomized Controlled Trial.

BackgroundType 2 diabetes is a common lifelong condition that affects over 400 million people worldwide. The use of effective medications and active self-management can reduce the risk of serious complications. However, people often have concerns when starting new medications and face difficulties in taking their medications regularly. Support provided by brief messages delivered through mobile phone–based SMS text messages can be effective in some long-term conditions. We have identified promising behavior change techniques (BCTs) to promote medication adherence in this population via a systematic review and developed SMS text messages that target these BCTs. Feasibility work has shown that these messages have fidelity to intended BCTs, are acceptable to patients, and are successful in changing the intended determinants of medication adherence. We now plan to test this intervention on a larger scale in a clinical trial.ObjectiveThe aim of this trial is to determine the effectiveness and cost-effectiveness of this intervention for reducing cardiovascular risk in people with type 2 diabetes by comparing it with usual care.MethodsThe trial will be a 12-month, multicenter, individually randomized controlled trial in primary care and will recruit adults (aged ≥35 years) with type 2 diabetes in England. Consenting participants will be randomized to receive short SMS text messages intended to affect a change in medication adherence 3 to 4 times per week in addition to usual care. The aim is to test the effectiveness and cost-effectiveness of the intervention when it is added to usual care. The primary clinical outcome will be a composite cardiovascular risk measure. Data including patient-reported measures will be collected at baseline, at 13 and 26 weeks, and at the end of the 12-month follow-up period. With 958 participants (479 in each group), the trial is powered at 92.5% to detect a 4–percentage point difference in cardiovascular risk. The analysis will follow a prespecified plan. A nested quantitative and qualitative process analysis will be used to examine the putative mechanisms of behavior change and wider contextual influences. A health economic analysis will be used to assess the cost-effectiveness of the intervention.ResultsThe trial has completed the recruitment phase and is in the follow-up phase. The publication of results is anticipated in 2024.ConclusionsThis trial will provide evidence regarding the effectiveness and cost-effectiveness of this intervention for people with type 2 diabetes.Trial RegistrationISRCTN Registry ISRCTN15952379; https://www.isrctn.com/ISRCTN15952379International Registered Report Identifier (IRRID)DERR1-10.2196/32918

Tool to improve patient-provider interactions in adult primary care: Randomized controlled pilot study.

To assess whether an intervention to help patients prioritize goals for their visit would improve patient-provider communication and clinical outcomes. Randomized controlled pilot study. Primary care clinic. There were 120 adult hypertensive patients enrolled. Patients were randomized to receive either usual care or a previsit patient activation card developed through a series of focus groups that prompted patients to articulate their needs and set priorities for their clinic visit. Encounters were audiorecorded, transcribed, and assessed using duplicate ratings of patient activation and decision making. The primary outcome was change in medication adherence as measured by pill count at 4 and 12 weeks after the initial visit. Secondary outcomes evaluated patient-provider interaction quality (patient satisfaction, patient activation, shared decision making, patient trust, and physicians' perceived difficulty of the encounter), functional status, and blood pressure control. Of the 120 enrolled patients, 106 completed the baseline visit (mean age of 66 years, 53% women, 57% Black, 36% White). Participants had multiple comorbidities (median number of medications = 8). During the visit, there was greater patient activation in the intervention arm than in the control arm (4.4 vs 3.8, P = .047; ratings were based on a scale from 1 to 10). However, after the visit there were no differences in medication adherence (4 weeks: 45.8% vs 49.5%; 12 weeks: 49.4% vs 51.1%), blood pressure control (4 weeks: 133/78 mm Hg vs 131/77 mm Hg; 12 weeks: 129/77 mm Hg vs 129/76 mm Hg), or encounter satisfaction (78.6% vs 73.8% fully satisfied; P = .63). There were also no differences in shared decision making, patients' trust, or perceived difficulty of the encounter. A single previsit tool designed to prompt patients to set a prioritized agenda improved patient activation during the visit, but did not affect the quality of the interaction or postvisit patient-centred outcomes.

Providers' mediating role for medication adherence among cancer survivors.

We conducted a mediation analysis of the provider team's role in changes to chronic condition medication adherence among cancer survivors. We used a retrospective, longitudinal cohort design following Medicare beneficiaries from 18-months before through 24-months following cancer diagnosis. We included beneficiaries aged ≥66 years newly diagnosed with breast, colorectal, lung or prostate cancer and using medication for non-insulin anti-diabetics, statins, and/or anti-hypertensives and similar individuals without cancer from Surveillance, Epidemiology, and End Results-Medicare data, 2008-2014. Chronic condition medication adherence was defined as a proportion of days covered ≥ 80%. Provider team structure was measured using two factors capturing the number of providers seen and the historical amount of patient sharing among providers. Linear regressions relying on within-survivor variation were run separately for each cancer site, chronic condition, and follow-up period. The number of providers and patient sharing among providers increased after cancer diagnosis relative to the non-cancer control group. Changes in provider team complexity explained only small changes in medication adherence. Provider team effects were statistically insignificant in 13 of 17 analytic samples with significant changes in adherence. Statistically significant provider team effects were small in magnitude (<0.5 percentage points). Increased complexity in the provider team associated with cancer diagnosis did not lead to meaningful reductions in medication adherence. Interventions aimed at improving chronic condition medication adherence should be targeted based on the type of cancer and chronic condition and focus on other provider, systemic, or patient factors.

Gender, Family, and Healthcare during Unemployment: Healthcare Seeking, Healthcare Work, and Self-Sacrifice.

This study investigates how healthcare seeking for oneself and "healthcare work" for family-constellations that include the continuation of health insurance, access to formal medical care, and medication adherence-change during a period of unemployment. "Intensive mothering" norms that promote selfless caregiving may discourage women's (but not men's) engagement in own healthcare seeking behavior. Breadwinning norms may oblige men (but not women) to provide income and other resources, including health insurance. This paper relies on data from 100 in-depth interviews with unemployed men and women conducted from 2013 to 2015. An iterative coding process guided data analysis; themes and patterns were evaluated to determine their importance across the data. After a job loss, many women (but few men) stopped seeking previously maintained healthcare for themselves. In contrast, some men rejected obligations to provide health insurance for their family. Moreover, the majority of women (but few men) discussed the prioritization of family in their healthcare decision-making. The intersection of financial inequalities and changing gender norms in healthcare seeking and family healthcare work placed a unique toll on women's health. These findings expand current understanding of how gender functions as a primary frame and how these frames change, suggesting that gender beliefs about family responsibilities extend to healthcare seeking and family healthcare work and are constrained by social class, even as gender frames change to reshape men's obligations to provide health insurance.